Inguinal Hernia

History

Fact

Explanation

Lump in the groin [2] [8] [10]

They most commonly present with a lump in the groin area due to bulging of the abdominal contents. The lump increases in size with standing up, heavy work, coughing, straining or any other instances in which intra abdominal pressure rises. It usually disappears when lying down. [2] [8] [10]

Vague pain in the groin area [2] [8] [10]

Sometimes patients present with a vague pain in the groin which again increases with heavy weight lifting, coughing, straining. [2] [8] [10]

Acute intermittent abdominal pain [4] [6] [7] [9]

A hernia can get obstructed and the patient can present with intestinal obstruction. Abdominal pain can be located according to the part of the intestine that gets obstructed and is classically intermittent. [4] [6] [7] [9]

Nausea, Vomiting [4] [6] [7] [9]

This is a feature of acute intestinal obstruction and usually when the part of the intestine which is obstructed is proximal. [4] [6] [7] [9]

Constipation [4] [6] [7] [9]

This is a feature of acute intestinal obstruction and mainly if large bowel gets obstructed. It can be absolute in which the passage of flatus doesn't occur as well. [4] [6] [7] [9]

Abdominal distension [4] [6] [7] [9]

More distal the bowel obstruction is greater the distension. [4] [6] [7] [9]

Increased thirst, Reduced level of consciousness [4] [6] [7] [9]

These are features of dehydration due to intestinal obstruction. With obstruction of the bowel oedema of the bowel wall occurs and fluid gets sequestered in the bowel lumen. It also causes defective absorption of fluid via the bowel wall. Additionally more fluid is lost due to vomiting. [4] [6] [7] [9]

NACHIMUTHU SENTHIL, GERGELY SZABOLCS. Strangulated inguinal hernia due to an omental band adhesion within the hernial sac: a case report. Array [online] 2009 December [viewed 04 September 2014] Available from: doi:10.1186/1757-1626-2-21

Examination

Fact

Explanation

Lump in the groin [1] [4]

The size of the hernia can increase with lifting of heavy weight, coughing, straining when the intra-abdominal pressure rises. When the patient is examined in the standing position, it appears and maybe apparent with coughing. Manual reduction maybe possible initially but when the hernia increases in size, it can get irreducible due to formation of fibrous adhesions. Direct and indirect hernias can be differentiated clinically only when the hernia is reducible. When the hernia is reduced, the finger is held over the internal ring and the patient is asked to cough. If the lump appears the hernia is direct and if not it's an indirect hernia as indirect hernias enter the inguinal canal through the internal ring. [1] [4]

Expansile cough impulse [1] [4]

Finger is held over the lump and patient is asked to cough which produces an expansile cough impulse.
Sliding hernias are probable with large scrotal hernias [1] [4]

Redness over the lump [5] [6]

There can be redness over the lump. This usually indicates strangulation of the hernia with resultant bowel ischemia. [5] [6]

Tenderness over the lump [5] [6]

There can be tenderness over the lump. Severe tenderness usually indicates strangulation of the hernia with resultant bowel ischemia. [5] [6]

NACHIMUTHU SENTHIL, GERGELY SZABOLCS. Strangulated inguinal hernia due to an omental band adhesion within the hernial sac: a case report. Array [online] 2009 December [viewed 26 August 2014] Available from: doi:10.1186/1757-1626-2-21

Differential Diagnoses

Fact

Explanation

Femoral hernia [1] [2] [3]

This appears in the thigh below and lateral to the pubic tubercle whereas inguinal hernias appear above and medial. Even though inguinal hernias are more common in males, femoral hernias are common in females. [1] [2] [3]

Hydrocele [4]

A hydrocele is a collection of fluid within the tunica vaginalis of the scrotum. It is possible to get above a hydrocele and the testis is bot separately palpable in a hydrocele. Additional clinical findings such as transillumination can also be observed. [4]

Spermatic cord hydrocele [7]

fluid collection along the spermatic cord is called a spermatic cord hydrocele. This is a developmental abnormality. [7]

Lymph node enlagement [8]

Enlarged lymph nodes in the groin due to an infective cause or a malignancy can mimic inguinal hernia. [8]

Groin abscess [9]

Abscess in the groin area also appear as a lump but will be tender and overlying skin may be reddened. Additionally patient may be febrile. [9]

Saphena varix [10]

This is a dilation of the saphenous vein at its junction with the femoral vein in the groin. [10]

Varicocele [11]

Dilatation and tortuosity of veins of the pampiniform plexus result in varicoceles. Patients present with scrotal pain and swelling, or as a cause of male infertility. [11]

Undescended testis [12]

There's failure of the testis to descend from its intra-abdominal location into the scrotum and can lie anywhere in it's usual pathway from abdomen to the scrotum. [12]

Investigations - for Diagnosis

Fact

Explanation

Ultrasound scan of the groin [1] [2] [3] [4]

This has nearly 100% specificity and can detect herniae [1] [2] [3] [4]

CT scan of the groin [1] [2] [3] [4]

If the ultrasound scan is negative and clinical suspicion is high further evaluation by CT of the groin may be done. But a negative CT scan will not exclude the possibility of a hernia and valsalva manoeuvre performed at time of the scan can increase the rate of detection. [1] [2] [3] [4]

Herniography [1] [2] [3] [4]

This is an invasive investigation therefore not commonly done. [1] [2] [3] [4]

MRI scan of the groin [1] [2] [3] [4]

Even though it's very sensitive and specific not commonly performed because this is an expensive investigation. [1] [2] [3] [4]

Urine full report [9]

This may be done to rule out a urinary tract infection as a urinary tract infection may cause pain in the groin that can be mistaken for hernia pain [9]

Full blood count [5] [6] [7] [8]

If strangulation is suspected, a full blood count may show high white cell count and high hematocrit due to dehydration. [5] [6] [7] [8]

NACHIMUTHU SENTHIL, GERGELY SZABOLCS. Strangulated inguinal hernia due to an omental band adhesion within the hernial sac: a case report. Array [online] 2009 December [viewed 26 August 2014] Available from: doi:10.1186/1757-1626-2-21

SHULMAN M. A., THOMPSON B. R.. I. Not fit for a haircut ... how should we assess fitness and stratify risk for surgery?. British Journal of Anaesthesia [online] December, 112(6):955-957 [viewed 26 August 2014] Available from: doi:10.1093/bja/aeu003

Management - General Measures

Fact

Explanation

Patient education [1] [2]

If the hernia is small, the patient may only need reassurance and education regarding the etiology, nature and available treatment options. He should be educated on warning signs of intestinal obstruction and when to seek treatment. Patient should also be advised to avoid smoking. [1] [2]

Treatment of predisposing factors [1] [2]

If there's underlying chronic cough, constipation, straining on micturition, these problems need to be properly addressed and should be treated prior to surgical management. As well as patient should be educated to avoid heavy weight lifting as this may aggravate hernia [1] [2]

Acute management of intestinal obstruction [3] [4] [5]

Patient is dehydrated, therefore normal saline intravenously given. Potassium can also be given. Nasogastric tube is placed to decompress the stomach. The patient should be monitored with regard to heart rate, respiratory rate, blood pressure, urine output, temperature and clinical status.
Administration of analgesia is important as patient is in pain and antiemetics are given as there's severe vomiting. Administration of antibiotics are to cover against gram-negative and anaerobic organisms [3] [4] [5]

NACHIMUTHU SENTHIL, GERGELY SZABOLCS. Strangulated inguinal hernia due to an omental band adhesion within the hernial sac: a case report. Array [online] 2009 December [viewed 26 August 2014] Available from: doi:10.1186/1757-1626-2-21

Management - Specific Treatments

Fact

Explanation

Emergency management of a strangulated hernia [1] [2] [4]

This becomes a surgical emergency through obstruction and incarceration and then emergency surgery is indicated for possible strangulation where the hernial sac is operated.[1] [2] [4]

Open repair of hernia [3] [7] [8] [9]

Bassini's operation invloves apposition of the transversus abdominis and transversalis fascia and the lateral rectus sheath to the inguinal ligament. The Shouldice technique is another surgical technique. But now Lichtenstein tension free hernial repair technique is widely used and a polypropylene mesh is used to reinforce the abdominal wall. Possible complications are Recurrence (rate is very low), ischemic orchitis, wound infection, bladder injury, intestinal injury, pain, hematoma formation. [3] [7] [8] [9]

Laparoscopic repair of hernia [5] [6]

Similar to any laparoscopic surgery, this has less postoperative pain and return to work is faster than in an open surgery. But it is expensive and not widely available. There are two approaches which are the transabdominal preperitoneal (TAPP) or the preperitoneal appraoch (TEP) procedure. In TEP peritoneal cavity is not entered into whereas TAPP needs entry into the peritoneal cavity. [5] [6]

Conservative management [7]

If the patient refuses surgery, a truss may be used. [7]

Management of a congenital inguinal hernia [10] [11]

The operation is undertaken as soon as possible either as open or laparoscopically. [10] [11]

References

NACHIMUTHU SENTHIL, GERGELY SZABOLCS. Strangulated inguinal hernia due to an omental band adhesion within the hernial sac: a case report. Array [online] 2009 December [viewed 26 August 2014] Available from: doi:10.1186/1757-1626-2-21